Adjuvant intraperitoneal chemotherapy with carbon-adsorbed mitomycin in patients with gastric cancer: results of a randomized multicenter trial of the Austrian Working Group for Surgical Oncology.

PURPOSE: Previous studies have demonstrated a beneficial effect of intraperitoneally applied mitomycin bound to activated carbon particles (M-CH) in preventing intraabdominal recurrence following curative surgery for gastric cancer. The Austrian Working Group for Stomach Cancer, a subgroup of the Austrian Working Group for Surgical Oncology, initiated a multicentric phase III trial to evaluate the safety and efficacy of this treatment regimen. PATIENTS AND METHODS: A total of 91 patients with a radically resected gastric cancer infiltrating the serosal surface were randomly assigned to receive either 50 mg mitomycin bound to a solution of 375 mg carbo adsorbens intraperitoneally before closure of the abdominal wound (n = 46) or served as a surgical control group (n = 45). Postoperative complications and recurrence-free and overall survival were evaluated to analyze the risks and benefits of this treatment. RESULTS: After a median observation period of 597 days (range, 72 to 1,096), a significantly higher postoperative complication rate was observed in the M-CH group (35%) compared with the control group (16%) (P < .02). In accordance with this finding, the postoperative (60 days) mortality rate was also significantly elevated in the M-CH group (11% v 2% in the control group). Since analysis of overall and recurrence-free survival failed to show any beneficial effect of M-CH therapy, the protocol committee decided to stop further recruitment of patients onto this study. CONCLUSION: Adjuvant intraperitoneal therapy of gastric cancer by mitomycin bound to activated carbon particles is associated with an increased rate of postoperative complications. However, no benefit for prognosis following radical resection of locally advanced tumors was observed in this multicenter phase III trial.

Hepatic resection for metastases from colorectal carcinoma--a survival analysis.

Between 1 January 1984 and 31 December 1992, 66 patients with hepatic metastases from colorectal carcinomas underwent liver resection. 40 of these patients had synchronous hepatic metastases, and liver resection was carried out simultaneously with radical resection of the primary tumour; in 26 cases metachronous metastases in the liver were surgically removed. 25 patients had an anatomical resection and the remainder underwent atypical resections. The postoperative mortality rate was 4.5% and the major complication rate was 19.7%. Univariate and subsequently multivariate analyses were used to predict the influence of various clinical, histopathological and surgical variables. The observed 5-year survival rate was 29.6% and the 5-year disease-free survival rate 13.9%. Furthermore, the observed median survival time was 24.7 months and the mean disease-free survival time was 16.7 months. Multivariate analysis showed that stage of primary (pTN) (P = 0.043), tumour grading (P = 0.013) and site of primary (P = 0.007) were factors which independently influenced 5-year disease-free survival whereas stage of primary (pTN) (P = 0.008), tumour grading (P = 0.004) and type of resection (P = 0.035) were identified as having independent influence on 5-year observed survival. We consider liver resection to be an effective form of treatment for patients with resectable liver metastases from colorectal carcinoma, although the overall chances for cure are generally not very promising. It appears that the biological behaviour of the primary tumour, in terms of tumour stage and grading, has the greatest influence on survival.

Recurrent nerve palsy after thyroid operations--principal nerve identification and a literature review.

BACKGROUND: Recurrent laryngeal nerve paralysis is one of the most frequent and serious complications after thyroid operation. The routine dissection and demonstration of the recurrent nerve remain controversial. In a retrospective study in an endemic region, patients operated on with principal nerve identification were investigated for vocal paralysis. METHODS: Eight hundred and three consecutive goiter operations were analyzed. Because six patients had undergone isthmusectomies only, the recurrent laryngeal nerves were at risk in 797 operations. For 736 patients the surgical procedure was primary for benign disease, for 40 patients the operation was secondary for recurrent goiters, and 21 patients underwent operation for thyroid cancer. All patients underwent preoperative and postoperative laryngoscopic examination of the vocal cords by an ear, nose, and throat specialist. RESULTS: Rate of primary postoperative vocal cord paralysis was 3.6%, and the permanent palsy rate was 0.5% with a recurrent laryngeal nerve recovery rate of 86%. In a literature survey, reports with identification of the recurrent nerve had significantly lower primary and permanent palsy rates when compared with reports without obligatory identification of the nerve (p < 0.01). CONCLUSIONS: Our results and those of reports in the literature indicate that recurrent nerve paralysis is a less frequent complication when the nerve is identified.

Long-term results of radical surgery for rectal cancer: multivariate analysis of prognostic factors influencing survival and local recurrence.

AIMS: To evaluate consistent radical surgery performed over a 13-year period for rectal cancer in terms of local tumour control and long-term survival. METHODS: Radical surgical procedure principally using total mesorectal excision (TME) for middle and lower rectal tumours, high ligation of the inferior mesenteric artery and sphincter-saving resections (SSR) whenever possible, has been performed prospectively since January 1984. RESULTS: Tumour resection was possible in 98.8% (636/644), potentially curative resections (UICC/AJCC R0 resection) in 85.7% (552/644) and sphincter preservation in 71.7% (462/644). Five- and 10-year observed survival rates, surgical mortality not excluded, for all patients were 49.2% and 37.4%. Tumour-adjusted 5- and 10-year survival rates were 60.5% and 55.3%. For curatively operated patients (UICC/AJCC R0) 5- and 10-year observed survival rates were 56.3% and 42.6% and tumour-adjusted survival rates were 68.6% and 62.7%. The 5- and 10-year local recurrence rates for R0 resected patients were 12.0% and 12.6%. Post-operative hospital mortality was 3.1%. CONCLUSIONS: Multivariate analysis using Cox's model identified increasing pT category and pN category, old age and low tumour location as detrimental factors having independent influence on survival. For local tumour failure only pT and pN category as well as adjuvant radiation therapy were identified in the Cox model as having an independent detrimental influence.

[Value of surgery in treatment of complicated gastroduodenal ulcer]. / Stellenwert der Chirurgie in der Behandlung des komplizierten gastroduodenalen Ulkus.

The surgical procedure in acute complications of gastroduodenal ulcers is examined with regard to risk factors and mortality. Emergency admissions to an Austrian district hospital between 1. 1. 1984 and 31. 8. 1992 for peptic ulcer are retrospectively analyzed. 293 patients were admitted with a history of bleeding ulcers. Endoscopic haemostasis was achieved in 91 of 130 (70%) patients with active haemorrhage (Forrest Ia, Ib). For the other 39 patients with active haemorrhage as well as for 16 of 65 patients with signs of previous bleeding (Forrest II) emergency surgery was necessary. 33 patients were admitted for perforated ulcers and all underwent emergency surgery. Distral gastric resections were performed in 98% of cases (54/55) with bleeding ulcers and in 91% of cases (30/33) with perforated ulcers. The surgically treated patients had a high percentage of accompanying illness and females were significantly older (mean 68 years) than males (55 years) (p < 0.01). Postoperative mortality was 9.1% (5/55) for bleeding peptic ulcers and 6.1% (2/33) for perforated ulcers. Furthermore, mortality was zero in patients younger than 60 years (0/44), but 15.9% (7/44) in patients older than 60 years. Distal gastric resection was chosen as standard procedure for emergency operations.

[Double stapling suture anastomosis in deep anterior rectum resection. Experiences and results]. / Die Doppel-Klammernaht-Anastomose bei tiefer anteriorer Rectumresektion. Erfahrungen und Ergebnisse.

Between 1.1. 1984-31.12. 1989, 263 rectal carcinomas were operated at the Department of Surgery, St. Veit/Glan. The resection rate was 68.4%, the excision rate was 27.8%, other procedures were carried out in 3.8%. Staple devices were used for all anastomoses following rectum resection. Whenever technically possible, the single-stapled procedure was used (EEA, ILS). For difficult or very low anastomoses, the double-stapled technique (DST) was utilized. The DST was employed in 47 cases. This approach contributed essentially to a relatively high resection rate at our department.

[Abdominal wall implantation metastasis 2 years after apparently uneventful laparoscopic cholecystectomy]. / Bauchdeckenimplantationsmetastase zwei Jahre nach scheinbar unauffälliger laparoskopischer Cholecystektomie.

An extraordinary rare case of implant metastasis at the laparoscopic working port, two years after an apparent uncomplicated laparoscopic cholecystectomy is presented. The histological reexamination of the gallbladder with the detection of a minimal carcinomatous lymphangiosis in newly prepared sections, the exclusion of other primary tumors and also the tumor-free interval of six months until now, after radical excision of the abdominal wall, are strongly suggestive for an intraoperative tumor cell dissemination into the abdominal wall by a histologically unrecognized carcinoma of the gallbladder.

Improving survival rates for patients with colorectal cancer.

Between 1 January 1984 and 31 December 1990, 575 patients were operated on for colorectal cancer. The surgical procedure was performed consistently and no patients were lost to follow-up. Almost half of the patients (284 of 575) had tumours of stage I or II, with 5-year survival rates over 90 per cent. After extending the resection margins in 28 cases of colonic carcinoma there has been no case of tumour recurrence. The overall 5-year survival rate for patients with colonic carcinoma was 81 per cent. Complete resection of the mesorectum was mandatory for rectal resection. One-third of the carcinomas in the lower third of the rectum could be resected with maintenance of bowel continuity and an abdominoperineal resection avoided. Not only was the tumour recurrence rate in the former patients lower (10.5 per cent) compared with that in those undergoing abdominoperineal resection (14.3 per cent) but the 5-year survival rate at 90 versus 52 per cent was significantly higher. The overall 5-year survival rate for patients with rectal carcinoma was 71 per cent.

Extended radical surgery against gastric cancer: low complication and high survival rates.

The present study examines survival benefits for 338 gastric cancer patients from radical surgical treatments, including radical lymphadenectomy of group 3 nodes and combined resection of infiltrated adjacent organs. Curative surgery, with no detectable residual tumor, was possible for 236 patients (69.8%). The radical surgical approach was constant in execution, with 330 of the 338 patients (97.6%) being operated upon by the same surgeon. The remaining patients were operated upon in a similarly radical manner which always included a lymphadenectomy of the N-3 region. Anastomotic leakage was observed in seven patients (3.0%). The postoperative mortality rate was 4.8% for total gastrectomy cases and 3.3% for subtotal gastrectomy cases. The actuarial five-year survival rate for patients receiving curative surgery was 50.0%. These low complication and high survival rates support the concept of extended radical surgery for gastric cancer.

Extended lymphadenectomy against early gastric cancer.

Fifty-three patients with early gastric cancer, operated upon by the same surgeon, were analyzed at a district hospital in central-Europe. The incidence of early gastric cancer was 17% (53/317). The lesions were restricted to the mucosa in 29 cases and invaded the submucosa in 24. Lymph node involvement was found in eight cases (15%), all with submucosal invasion. Generalized tumor recurrence occurred in two cases, both with lymph node involvements pN-2. The actual-five-year survival rates were 96% for the mucosal lesions and 86% for the submucosal lesions. Extended lymphadenectomy is essential in the surgical treatment of early gastric cancer. Results achieved previously only in Japan are now achievable elsewhere by applying their methods. We could demonstrate that it is possible to achieve as high survival rates for early gastric cancer in central-Europe as in Japan. We accredit this progress to the extended lymphadenectomy performed in all cases.

Extraperitonealization of the anastomosis and sacral drain in restorative surgery for rectal carcinoma: a safety mechanism in the absence of a covering stoma.

A retrospective 10-year study was conducted on 473 patients who underwent rectal cancer surgery, to evaluate a surgical procedure which has been generally abandoned, but which we believe has a significant potential to reduce the incidence of the severe and often fatal complications caused by anastomotic breakdown following low anterior resection, especially when a covering stoma is absent. This procedure involves separating the anastomosis and sacral drain from the abdominal cavity by suturing the parietal peritoneum to the colon and mesocolon, and placing the sacral drain outside the peritoneal cavity, whereby contamination of the abdominal cavity is avoided should anastomostic leakage occur. Sphincter preservation was possible in 343 patients (72.5%) while 116 (24.5%) underwent abdominoperineal resection (APR). Of 331 patients who underwent sphincter-saving resection (SSR), 31 (9.4%) had primary protective colostomies. Radical RO-resection according to the International Union Against Cancer (UICC) was performed in 405 patients, and 65 (19.6%) underwent extended resections. Anastomotic leakage became clinically manifest in 33 patients (10%; or 11% when those with primary colostomies were excluded). Only 1 patient required relaparotomy while 32 were successfully treated with temporary loop colostomy in the right epigastrium. No deaths occurred following anastomotic leakage breakdown. Overall operative hospital mortality was 3.0%; 2.7% and 2.6% in the SSR and APR groups, respectively. The adjusted 5-year survival rates were 60% for APR and 72% for SSR.

[Surgical emergency interventions in acute diseases of the large intestine]. / Der chirurgische Notfalleingriff bei akuten Dickdarmerkrankungen.

Emergency operations due to acute colonic disease between 1. 1. 1984 and 31. 12. 1991 were retrospectively analyzed with regard to causality, surgical procedure, complications and mortality. 55 of 1105 colonic operations were emergency cases requiring immediate surgical intervention. Primary continuity preserving resections were carried out whenever possible, attending not only to the acute situation but also to the primary disease. The mean age of the 26 females and 29 males was 69 [1, 9] years. 29 patients had a colonic ileus, 21 a diffuse peritonitis and 5 patients had an uncontrolled haemorrhage. Colorectal carcinomas were initially diagnosed in 20 of the 50 patients; 14 of these patients (70%) could be operated for potential cure and primary continuity preserving resections were also possible for 14 patients (70%). Continuity preserving resections were possible for 18 of 21 patients with peritonitis and 3 colonic perforations were oversutured. In the 5 patients with acute haemorrhage, 4 resections and one transanal intervention were performed. Postoperative complications were observed in 19 patients (35%). Postoperative mortality was 16% (9/55), 5% for operations due to peritonitis, 24% for operations due to colonic ileus and 20% for operations due to haemorrhage. Primary continuity preserving resections were possible for 39 of 55 patients (71%).

Simultaneous resection of colorectal carcinoma and synchronous liver metastases in a district hospital.

Of 491 patients operated for carcinomas of the colon or rectum between 1984 and 1989, 106 were tumour stage IV, U.I.C.C.(Dukes' 'D') at time of operation. In 22 of these cases a radical resection of the carcinoma of the colon or rectum and of synchronous liver metastases was performed simultaneously. In 20 patients the metastases were confined to one, in two they were found in both hepatic lobes. In one case a solitary metastasis of the lower lobe of the right lung was resected additionally. Three right-sided hemihepatectomies, one extended right hemihepatectomy, five left-sided hemihepatectomies, three left-sided lateral segmentectomies, seven atypical segmental resections and three wedge resections were performed. The mean operation time for the radical resection of the carcinomas of the colon or rectum as well as of the liver metastases was 3.5 (3-5.2)hours. An average of 3 (0-9) blood units were needed intraoperatively. The major liver resections were performed in complete normothermic vascular ischaemia using the finger fracture method. The time of ischaemia ranged between 8 and 25 min. Only 1 of 22 patients died postoperatively (30 days postoperative hospital mortality rate 4.5%). Five of 17 patients were free of tumour 2 years after operation. Eight of 22 were alive 2 years after operation (non-age corrected 2-year survival rate 36.4%), 2 of them are alive more than 5 years after treatment. Our results demonstrate that simultaneous resection of colon or rectum carcinoma and of synchronous (resectable) liver metastases can be performed successfully, even in a district hospital.

Long-term survival analysis of gastric cancer limited to the subserosa.

Long-term survival following surgery for gastric cancer limited to the subserosa was analyzed. Between 01.01.1984 and 30.06.1995. 265 patients were operated for gastric cancer that did not invade beyond the subserosa. Extended lymphadenectomy was performed in all cases and was constant as all patients were operated by only two surgeons. The survival outcome was analyzed with particular regard to the exact depth of tumor infiltration and lymph node involvement. The percentage of patients with positive lymph nodes increased drastically from 1.7% for mucosal invasion to 22.7% for submucosal tumor involvement. A further substantial increase was observed from 34.3% for involvement of the muscularis propria to 66.1% for subserosal involvement. The 10-year tumor specific survival rate for tumors limited to the mucosa was 100%, for submucosa and muscularis propria invasion 79.3% and 72.9% respectively, for subserosal involvement 10-year survival was 54.6%. In multivariate analysis of pathohistological variables only pT- and pN-categories according to the UICC were found to have independent prognostic influence on survival. Long-term survival indicates that gastric cancer limited to the mucosa may well be treated with a less radical approach. Gastric cancer of the submucosa and muscularis propria both have a similar good long-term prognosis with radical surgery alone whereas cancer of the subserosa probably requires some form of adjuvant therapy.

A first report of familial visceral myopathy with additional chylous ascites in two siblings.

BACKGROUND: Familial visceral myopathy in two siblings, involving the intestine with concurrent chylous ascites and chylous pleural effusion, is reported. In this connection a review of the recent gastroenterologic literature was performed. PATIENTS: In two siblings, admitted between 1992 and 1995 with increasing ascites, loss of weight, and attacks of subileus, the diagnosis of familial visceral myopathy was established. CASE ONE: During the initial preoperative examination hepatogenous ascites was diagnosed. Visceral myopathy and chylous ascites were subsequently established by means of an explorative laparotomy in conjunction with histologic examination of specimens taken from the small-bowel wall. CASE TWO: The patient's brother was admitted 3 years later with similar symptoms. Complaints of chylous ascites and chylous pleural effusion in connection with attacks of subileus are still present. OUTCOME: The female sibling was discharged from hospital with unchanged complaints and died only a few months later; the male sibling is still alive, but with unchanged complaints. CONCLUSIONS: Rare cases of familial and sporadic myopathy have been reported in the recent literature, but to our knowledge these are the first cases with concurrent chylous ascites and chylous pleural effusion in this uncommon disorder.

Multivariate comparison of complications after laparoscopic cholecystectomy and open cholecystectomy.

OBJECTIVE: To answer the question whether laparoscopic cholecystectomy (LC) or open cholecystectomy (OC) is safer in terms of complications, the authors evaluated complications relating to 1440 cholecystectomies performed by the same surgeons in a retrospective study. SUMMARY BACKGROUND DATA: A definite pronouncement on whether LC truly is superior to OC is not possible because prospective trials are burdened with problems of recruitment. METHODS: After the introduction of LC at the authors' institution in April 1991 and until October 1993, 94.6% (700/740) of all patients admitted for operation because of symptomatic gallstone disease could be treated laparoscopically. The clinical records of the last 700 patients who underwent OC before the introduction of LC were re-evaluated with regard to both overall complications and the grade of complication (severity grade 1-4). A comparison of the incidence of complications relating to the two surgical methods, age, sex, common bile duct stones, acute cholecystitis, concomitant illness, Apache score, and length of operation was calculated by multivariate analysis using the logistic regression model. RESULTS: The total rate of complications in the OC group was 7.7%, with five postoperative deaths, compared with 1.9% and one postoperative death in the LC group. Multivariate analysis for OC revealed that both old age (p = 0.014) and the existence of common bile duct stones (p = 0.02) had independent prognostic influences in increasing the overall complication rate, whereas only old age (p = 0.019) influenced the overall complication rate after LC. Multivariate analysis of all cholecystectomies (n = 1440) showed that the overall complication rate was influenced independently by OC as a detrimental factor. CONCLUSIONS: As this analysis emphasizes, LC can be performed safely with an overall complication rate that is distinctly lower than that of OC. For selective surgery, LC is undoubtedly superior to OC and can probably be seen as a new "gold standard" for cholecystectomies.

A 10-year experience with Japanese-type radical lymph node dissection for gastric cancer outside of Japan.

BACKGROUND: The prognosis for surgically treated gastric cancer remains poor in most Western countries compared with reports from Japanese investigators during the past 3 decades. METHODS: A radical surgical procedure principally to extended lymphadenectomy as defined by the Japanese Research Society for Gastric Cancer was performed prospectively from January 1984 to June 30, 1994 for 512 patients with gastric cancer, 345 of whom were treated with potentially curative surgery. Clinical, histopathologic, and surgical factors were examined for their influence on long term survival by univariate and multivariate analyses. RESULTS: Five- and 10-year survival rates for all patients were 40.5% and 34.3%, respectively, and for patients who underwent tumor resection were 45.7% and 38.6%, respectively. For patients who underwent curative surgery, 5- and 10-year adjusted survival rates were 57.7% and 44.3%, respectively, with a median survival of 96 months. Postoperative hospital mortality was 6.8%:4.9% for R-0 resected patients, 9% for R-1 and R-2 resected patients, and 13.4% for those with palliative procedures. Multivariate analysis using the Cox model identified age older than 65 years, prior total gastrectomy, an increasing number of positive lymph nodes, a high pathologic N classification, male sex, a high pT classification, and low preoperative hemoglobin level as detrimental factors with an independent influence on survival. CONCLUSION: Radical lymphadenectomy in this 10-year Austrian study yielded survival rates similar to those in Japanese investigations without sacrificing low postoperative mortality. In particular, the relatively high overall survival rates seemed to reaffirm the value of radical lymph node dissection with wide resection margins.

[Stomach carcinoma. Optimizing therapy by extended lymph node dissection]. / Magenkarzinom. Optimierung durch Erweiterung der Lymphknotendissektion.

BACKGROUND: The prognosis for surgically treated gastric cancer patients remains poor in most Western countries compared with reports of Japanese investigators over the last three decades. The aim of the study was to prove whether D2, D3 lymphadenectomy is able to improve long-term survival in a Western gastric cancer patients collective as well. METHODS: A radical surgical procedure using D2, D3 lymphadenectomy on principle as defined by the Japanese Research Society for Gastric Cancer was done prospectively since January 1984. Out of 626 patients with gastric cancer, 433 were surgically treated for potential cure between January 1st, 1984 and December 31st, 1996. Postoperative complications and long-term survival were evaluated. RESULTS: For curatively operated patients five- and ten-year tumor specific survival rates were 57.7% and 44.3%, the median survival time was 96 months. Postoperative hospital mortality was 4.8% for R0 resected patients and 10.4% for palliative procedures. CONCLUSION: Radical D2, D3 lymphadenectomy yielded survival rates similar to those in Japanese investigations without negative effect on low postoperative mortality. These results reaffirm the value of radical lymph node dissection with wide resection margins.

Radical surgery (R2 resection) for gastric cancer. A multivariate analysis.

BACKGROUND: Extended lymphadenectomy remains controversial in the Western world. Its evaluation and the identification of high-risk patients after surgery are important tasks. METHODS: A retrospective prognostic study of 318 patients treated for potential cure of gastric cancer was performed. All patients underwent extended lymphadenectomy. Clinical histopathologic and surgical factors were examined for their influence on survival by univariate and multivariate analysis. RESULTS: Postoperative mortality was 4.4% (14 of 318), and the 5-year adjusted survival rate was 57.8%. Multivariate analysis using the Cox model identified seven factors as having independent influence on survival. Detrimental factors were male gender, age over 65 years, high pN category, increasing number of lymph nodes invaded by metastases, total gastric resection, splenectomy, and increasing number of perioperatively required blood units. CONCLUSION: Extended lymphadenectomy was possible without sacrificing low postoperative mortality rates. The importance of certain prognostic factors, in particular lymph node status, could be confirmed.